PRB Discuss Online: How Can Family Planning Programs Reduce Poverty? Evidence From Bangladesh

(January 2010) Family planning is one of the most cost-effective health interventions in the developing world. For a relatively modest investment, family planning saves lives and improves maternal and child health. A new study of Bangladesh’s Matlab project provides some of the first evidence that family planning and maternal and child health programs also help lift families out of poverty—which makes these programs even more valuable. What policies and systems implemented in the project villages were crucial to Matlab’s success? Can the Matlab experience be replicated in other areas?

During a PRB Discuss Online, Shareen Joshi, visiting professor at Georgetown University, answered participants’ questions about the history and experience of the well-known Matlab project in Bangladesh, and whether it can be a model for other successful programs.

Jan. 28, 2010 1 PM EST

Transcript of Questions and Answers

Dr Gerry MAKAYA: That not really a question i mean that if that program or project has successed somewhere, it must be shared for other countries. So i’m head of district health in DR Congo. ive realised that the cause of poverty the people in my District can be because the familyplanning is not really integrate in our health system. my question now is with your acknowlge in your area of experience how can you explaned that the planning family can be the solution poverty in the developipment country. Thanks Shareen Joshi: I agree that we should not follow a “one-size-fits-all” approach towards development policy. The Matlab experiment should not be viewed as a recipe that would have the same results elsewhere. The experiment does however, offer some broad lessons. Firstly, it confirms the importance of investing in preventive health care (and including family planning in this package of care). Secondly, it highlights the importance of investing in strong health-care delivery systems at the local level. The Matlab program had excellent local organization. The local health care workers were carefully selected and trained. They eventually gained tremendous respect in their communities. Finally, the experiment illustrates that the benefits of such interventions accrue on long time-horizons. The link between health improvement and policy-alleviation takes time to manifest!

Dr. Anima Sharma: Dear Ms. Joshi, You have selected a very pertinent question for the discussion. When we talk about social development then there are few direct indicators and few indirect. The population is one of the factors, which may play a vital role in the incidence and increasing the gravity of the problem of Poverty. In India though family planning programmes are running since several decades, but still due to several religious and sociocultural factors those are not so effectively implemented. As a result there are many families having limited source of income but disproportionately high number of consumers. As a result the national per capita index are drastically on the leaner side in such cases. Most of such families thus fall in the lower to poverty stricken group. But still because of the factors as sighted above those people cannot be asked to follow the family planning programmes. Can you cite any remedy to this problem through any first hand study? Shareen Joshi: I think India has some important policy successes. In their book, “India: Development and Participation”, Dreze and Sen talk about this at length, but I will try to summarize at least one example here. Consider for example, the state of Tamil Nadu. Today, it has replacement level fertility (2.0 children per woman) and one of the lowest child mortality rates in India. It accomplished this over a 20 year period in the absence of high levels of GDP growth. We can learn a lot from Tamil Nadu’s experience. First, it has established an excellent infrastructure for health-care delivery. Infant mortality and maternal mortality is much lower than the national average, immunization is almost universal and pre-natal and ante-natal care levels are almost universal as well. Dreze and Sen also summarize some findings about the qualtity of health care in Tamil Nadu. Studies have found that primary health centers are well supplied with basic drugs. 40—45% of medical officers are women “Auxilliary Nurse Midwives” are better supervised than in most other Indian states and are provided with a lot of support. Emergency medical care is far more accessible than in other places. To me, this example offers many of the same lessons as Matlab—fertility decline can be achieved not only by expanding access to contraception, but by improving the health of mothers and children. This requires investing in preventive health and primary health delivery at the local level.

Nnennaya Igwe: “Development is said to be the best contraceptive” Some people because of their level of development are having too many children than they can take care of while others have equally decided not to have children at all also because of their level of devlopment. How do we reach a compromise? Shareen Joshi: Yes, it is true that development is a contraceptive. There are strong positive correlations between measures of development(GDP-per-capita, schooling enrolment, literacy rates, life-expectancy, infant mortality, etc.) and fertility rates. But the problem is that in the short-run at least, there is significant variation, and there is no tight relationship. To see this, lets do three comparisons – (i) Bangladesh and Mali, (ii) Lao PDR and Zambia, and (iii) Nepal and Uganda. In 2005, each pair displayed similar levels of GNI per-capita (current US dollars) but their total fertility rate (TFRs) are vastly different. Bangladesh, Lao PDR and Nepal had TFRs below 3.5. Mali, Zambia and Uganda have TFRs that are nearly double of their counterparts! Country Income TFR Country Income TFR Bangladesh $440 2.9 Mali $450 6.6 Lao PDR $480 3.3 Zambia $500 5.3 Nepal $300 3.1 Uganda $290 6.8 Data: World Development Indicators, 2009 Here, the lessons from Matlab are really important. We can see that fertility decline can occur without waiting for GDP-per-capita (or any other development indicator) to reach some sort of critical “threshold” level.

Jann Anguish: It is obvious that the Family Planning Programs improve the lives and health of the participating women. Are there any downsides to the program? Shareen Joshi: It can be expensive. Moreover, supply chains for preventive health inputs are very difficult to establish and maintain. For example, the task of getting injectables/vaccines into villages and keeping them cold until they could be administered to women in their homes at exactly the right time was not trivial! The temperatures are high, flooding is common, roads are often blocked or submerged, and electricity supply is erratic at best.

Nnennaya Igwe: What were the family planning methods the people adopted? Did they have preference for any? If yes, why? Shareen Joshi: A range of options were presented to women, including condoms, injectables, pills, IUDs, etc. I believe injectibles and pills were the most commonly chosen option.

Joshua Munguia: I have wanted to ask someone why doesn’t the World Health Organization promote vasectomies to younger men. Wouldn’t that be the logical thing to do, if the goal is to curve the birth rate. The promotion of other contraceptives in a developing country does not seem to be prevailing. I would think that the pill for women would be too costly, and that condoms for men are not always ready available. A procedure that would have a one time cost of only a two to three hundred dollars, and would actually be a permanent prevention seem to me, a good idea. Shareen Joshi: I think this approach has been discussed and even used in some places (for example, in India). It is not more common because there is potential for human-rights violations at the local level, and generally people prefer technologies that help them space-out their births.

Margret Karsch: Bangladesh always serves as an example for the success of family planning and of the demographic dividend: If the average number of children per woman is shrinking, the working population will grow in the following decades (there will be more employable people and less children and old-aged people). This is a chance to invest in education, health etc. Is Bangladesh using this opportunity – taking into account that many people are working in agriculture, many people don´t have a job, and corruption is still a problem? Or is the country running the risk of experiencing a growing poverty in the future? Thanks. Shareen Joshi: Bangladesh’s schooling and health indicators have shown significant improvement in the past thirty years. Today, primary school enrolment rates exceed 90% for both boys and girls and infant mortality and child mortality rates have fallen significantly as well. In the past ten years, it has shown steady GDP growth of between 4–5 percent per year. While more probably needs to be done to reap the benefits of the demographic dividend, these numbers are somewhat encouraging. Note: I got all these numbers from Bangladesh’s country profile at the World Bank website.

Nnennaya Igwe: Apart from the government activities, what other programs were in existence before or during the FPMCH in Matab that may have contributed to its impact and outcome? Shareen Joshi: There was a cholera vaccine trials in the 1960s. A family planning program (targeted at women) was also attempted about two years before the FPMCH program was established. This was largely unsuccessful because of the failure to provide follow-up services. The FPMCH incorporated the lessons of that program.

Carina Stover: There is concern that long-lasting and permanent methods of family planning are not popular and will be replaced with a program emphasis on short term methods like oral contraceptives. What do you think about this? Shareen Joshi: This program featured a broad set of contraceptive choices for women, both temporary and permanent. That was one of the most significant features of this project—it offered women a menu of choices and provided rigorous follow-up support, as well as the option to change methods. It also provided pre-natal, ante-natal and early childhood preventive health inputs. You can read more about all the different services in the broad literature on Matlab. One short paper that summarizes the services and the delivery of the services is:

Cecily Westermann: I know that the Cairo Protocol discourages incentives for practicing sterilization and other contraceptive means, but it seems that incentives would be a good way to go. Kind of a WIN/WIN for cash. How do you feel about offering incentives? Shareen Joshi: I do not have a view on this at the current time. There are some randomized controlled trials underway in Sub-Saharan Africa (William Dow at Berkeley is one of the PIs) where individuals are given cash transfers as long as they continue to test negative on a set of STIs. The results are not in yet, but I think those will begin to inform us on the merits and demerits of this approach. I suspect however, that even if this approach is successful, the issue of cost will surface. For cash incentives to work, they need to be significant. That adds to program cost, often at the expense of delivering services to more people.

Donald A. Collins, President: Bangladesh is not a failed state like Haiti and others. Can your program work there? Read my January 23, 2010 Haiti OP ED at www.vdare.comShareen Joshi: I think the Matlab experiment shows that family planning and child health programs CAN have an impact in rural and impoverished settings. There may however, be some serious impediments in setting up a program like it in a failed state. As I mentioned earlier, the organizational and logistical requirements of programs such as Matlab are significant in the short-term as well as the long-term. Setting up supply chains for preventive health inputs, and delivering services year and after year for decades is a substantial commitment on behalf of funding agencies, the national government, local government, and local organizations. The program may not be well-suited for an environment which lacks these types of support, and where there are high risks of service disruption.

Dr. Khaled Shamsul Islam: Only Family planning programs can reduce poverty? I think proverty related with social deteminanats like Education, Family background, Income level, purchase power parity etc. am i corrected? Shareen Joshi: I don’t think I would ever dream of suggesting that only family planning reduces poverty. There are many attributes and many causes of poverty—economic, social, cultural, institutional, political, demographic, etc.—and all of those matter. There are many types of poverty alleviation programs. We have explored just one and leave it to others to educate us about the many others!

Emeka Nwosu, Nigeria: What is the relatioship between family planning and poverty Shareen Joshi: This is a topic that is the subject a great many books and papers! One of the best overviews of all this literature is found on the website of the “Population and Poverty Research Network” (www.poppov.org). I would suggest looking at some of the background papers and current research papers on this subject!

Rick Bein: How do you get past that children are an asset in poor rural areas. The children provide a labor force in agriculture and security for parents in old age. They want to have as many children as possible. Shareen Joshi: Thanks to the work of Nobel Prize laureate Gary Becker, economists have long-believed in a “quantity-quality tradeoff”. The idea is that families don’t just want more children, but they want surviving and high-quality children. In order to achieve this, they must balance their preference for high fertility with greater child spacing, greater investments in children’s health and education, etc. Family planning programs can help people space their births better, raise healthier and higher “quality” children and be healthier themselves. It thus gives them the means to achieve higher SURVIVING fertility and better “quality” children rather than just higher OVERALL fertility. This is what our Matlab work is highlighting.

Holly Stover: When the program was initiated, was there any resistance or hesitation from the groups? Shareen Joshi: Yes, there was quite a bit of resistance. Some community health workers reported that senior members of the household (husbands, fathers-in-law and mothers-inlaw) were reluctant to allow them access to the younger women in the household. Over time however, the health care workers became far more than just providers of contraception. They were able to dispense valuable health advice, report emergencies to medical authorities and thus save lives, and win a great deal of trust from their community members. This helped overcome the resistance and they soon became well-respected in their communities. These developments—and many more aspects of this program’s social impact—are summarized in Fauveau’s book entitled “Matlab: Women, Children and Health”.

Austin Dunlap: The long-term benefits of EFFECTIVE family planning is evident. What other less developed countries are set to begin a family planning program? Also, how are these programs enforced in less developed countries (as they are more typically in need of population control) where little effective government oversight and/or resources are available? Shareen Joshi: Family planning programs became very popular instruments of development policy in the 1960s and 1970s. They varied in size, scale and delivery systems, but are believed to be quite successful in many places such as East ASia and Latin America. A review of many of these programs is found in a new publication from the World Bank called “The Global Family Planning Revolution”, available at: http://siteresources.worldbank.org/INTPRH/Resources/GlobalFamilyPlanningRevolution.pdf. Sub-Saharan Africa was unfortunately one region where the programs remained quite weak. There are a lot of different reasons for this—weak primary and preventive health care systems, fluctuations in funding, domestic politics (and the lack of popularity of these programs), skepticism about whether they can work in the socio-cultural environment of Africa, etc. Even in Africa however, experiments like the Navrongo experiment in Ghana, suggest that family planning programs can indeed work if they are delivered well and have strong local support. You can read about this project here: http://www.popcouncil.org/pdfs/wp/208.pdf

Prof. Dr. Claus D. Kernig: Will not the reduce of poverty better work in the sense of family planning then the other way round? What caused fertility reduction in the West? Was is not higher welfare, rising income and better social security? What are you doing in this respect? Can you prove that the fifth quintile became rich by having less children? Shareen Joshi: The demographic transition in the West took more than 150 years and was the result of a variety of factors: expanded public health systems, improvements in medical technologies, improvements in nutrition, and of course economic factors such as increases in incomes, the expansion of social security systems and increases in the costs of raising children. The demographic transition that is underway in the developing world is occurring much quicker. Transfers of public health and medical technologies, improvements in nutrition and the increase in growth rates has taken place at a much more rapid pace than the developed world. As an example, consider life expectancy. Life expectancy in India was about 30 in 1947. It is nearing 70 today. China is very similar. Such increases took nearly 200 years in the developed world! The rapid speed in the decline of death rates (indeed one of the biggest policy successes in the past 50 years) imposes on us the need to act to reduce birth rates as well. The natural forces of economics are already pushing birth rates down, but voluntary family planning programs can also have a role? As for proving that fertility reduction led to poverty reduction, no we can’t “prove” it because the program delivered more than just contraceptives. We can certainly say that women who used family planning and child-health services were better off in terms of health and economic well-being.

Ghazy Mujahid: Could you please tell us what lessons are provided by the Matlab on how important for the success of a reproductive health (RH) programme is the support of religious leaders. In the case of Bangladesh, this would be mainly the imams (prayer leaders) of mosques. Shareen Joshi: I think the only lesson on this from Matlab is that demographic change and fertility decline can occur in a conservative muslim society. To see this even better though, it is best to consider the case of Iran. It experienced faster fertility decline than any other country between 1985 and 2000. The government of Iran made family planning a national priority and set up a separate department to promote family planning. The strategy was approved by Iran’s most senior religious leaders. A fatwa was issued, calling for consent by couples and the use of methods that minimize side-effects and are reversible. Religious leaders all over the country supported this and participated in a communications campaign whose goal was to reduce fertility. This is a truly interesting example of how much support from religious leaders can matter!

Meskerem Bekele, Ethiopia: Dear ShareenI agree that family planning is one of the most cost-effective interventions in the developing world. In Matlab’s experience which sector and which group are more effective? Do you understand what I mean? I believe that media is the most powerful and using each society groups like religious leaders, policy makers and others also the other. According to media can they use religious media? How could they faced the cultural and religious influences? Can you compare and see any similarities from other developing countries to follow Bangladesh’s success? Shareen Joshi: Yes, I think there are many ways of influencing reproductive behavior. This program is only one example. There are other methods of reaching people—communication campaigns, involvement of local, national and religious leaders, etc. Iran provides an interesting example. Their family planning programs had a lot in common with the Matlab program—focus on voluntary and temporary contraceptive methods, delivery by local female health care workers, a focus on primary health as well as family planning, etc. But they also had an effective national communications campaign. The government of Iran’s family planning strategy was approved by Iran’s most senior religious leaders. A fatwa was issued, calling for consent by couples and the use of methods that minimize side-effects and are reversible. Religious leaders all over the country supported this and participated in a communications campaign whose goal was to reduce fertility. So yes, absolutely, the media can be powerful.

waldhanso Golocha: I do believe that family planning helps to reduce poverty. But the evidence we have at hand now is weak. Many poor countries were not convinced to include family planning in their poverty reduction strategies. My question is Why isn’t any randomized trial made to learn this effect yet? Shareen Joshi: The evidence has been difficult to find because we had great theories, but did not have good datasets to test them with (population and poverty both change together and are affected simultaneously by many variables, making causal relationships difficult to find). This is changing. I think the paper Paul and I wrote provided some evidence here. Moreover, there are many studies underway that also examine these relationships. You can read about many of them at www.poppov.org The bigger reason for the absence of family planning in PRSPs or even the MDGs for that matter, is that the international policy environment has moved away from family planning in recent years. You can read about this in Steve Sinding’s paper in the recent World Bank review (http://siteresources.worldbank.org/INTPRH/Resources/GlobalFamilyPlanningRevolution.pdf)

J.C. King: Hi Shareen, To me, poverty is only a state of mind. In some countries, having many children is necessary. However, there are also negative outcomes to having too many children. I’m all for the education of people through FP implementation except that I draw the line when it comes to abortion. Can these educational and assistence programs exist in other countries without taking on the “demons” that plague our own FP system here in the USA? Shareen Joshi: My expertise does not extend to the issue of abortion and/or abortion policy, either domestically or internationally. I am very much a scientist and limit my engagement in this area to an analysis of data and the inference of what I see in the data. The Matlab project did not provide any abortion options (unless the life of a mother was at risk) and so I do not believe this project offers any insight into this. I will say however, that controversies over abortion have in recent years led governments and policy-makers to back away from family planning programs completely (this is particularly after Cairo). This has made it difficult to even support programs that were once popular and working.

Nnennaya Igwe: What do you have to say about female condom and cycle beads as contraceptive options? Do people adopt them? Shareen Joshi: I think cycle beads are a terrific option to add to the offerings of contraceptives in voluntary family planning programs! The Institute of Reproductive Health has many studies on the effectiveness of this method!

Tricia Petruney: Sometimes it seems to me that the FP world is obviously bought into FP=development, and clearly understands the relationship. One of the issues is really getting development leaders to raise FP’s profile in their advocacy and decision-making. Do you have any recommendations for how to strengthen their engagement? Shareen Joshi: I am an academic and while I sometimes help policy-makers make sense of academic literature, I know little about advocacy or the mechanics of how policy is made. I think there are some wonderful experts at the PRB for this and would defer to them!

Seyi Olujimi: How can adoption of family planning bring about reduction in poverty? Is there

a correllation between increase in use of FP and increase in family well being? As a researcher and M&E person, I’m interested in what variables to measure. Can use of FP reduce poverty even when the economic environment is not conducive, like in Nigeria? Shareen Joshi: I think this is what our paper is about! The variables in the brief and in our 2007 paper may be worth considering if you are doing M&E in the long run. In the short-run women’s weights and BMIs, and the health of their children, are the best places to look for the beneficial effects of family planning and preventive health programs.

Tricia Petruney: To add to Cecily’s question about incentives, what about the flip side? What do you think about providing incentives for providers? This is done in certain areas of India. One the one hand, it may encourage non-FP providers to rememer to screen, counsel, and provide ut on the other it might slide into coercive tactics. Have you had any experience with provider-side incentives? Shareen Joshi: I do not have experience with provider-side incentives and worry greatly about the risk of human-rights violations and coercive methods that may follow from such incentives. Even in India, these methods have not been met with success. Please see my earlier example from India about Tamil Nadu. That offers a different take on provider incentives!

Asif Wazir: I am wondering about what relation between family planning and poverty. In my viewpoint, this is only one way negative relation, that poverty has an effect on family planning not vice versa. what do you thing in this regard? if there is any other relation, please explain. Shareen Joshi: There is a huge literature on the two-way relationship of population and poverty. I would recommend looking at some of the literature on the website of the “Population and Poverty Research Network” (www.poppov.org) for some great background papers as well as current studies on this issue.

sadia: Simultaneous to the FP programs, there has also been a focus on increasing female education and women’s employment opportiunities through various micro=credit programs. i wonder if you could share your [thoughts] on the [effects of] … those programs on economic well being Shareen Joshi: Indeed there has been great interest on this. I am not an expert expert on either education or micro-credit, but I do believe that they can both be powerful drivers of poverty-alleviation. I wish I could refer you to current evidence of these links. The best source repository of information for this is again, www.poppov.org